The midterm elections are dredging up talk of Obamacare once more, but the Democrats are not calling it by its name.

Heidi Heitkamp, a vulnerable Democrat from North Dakota running for Senate re-election, attacked her Republican challenger in a digital ad campaign for his votes to repeal President Barack Obama’s Affordable Care Act.

Her challenger, Kevin Cramer, has been a representative for North Dakota in the House since 2013.

"This is Denise," Heitkamp says in the 30-second spot released on Aug. 16. "She lives in Kildeer. Like 300,000 North Dakotans, Denise has a pre-existing condition. That used to mean no health insurance. For me it’s breast cancer, for Denise it’s heart disease."

"She has something she’d like to say to Kevin Cramer. ‘Mr Cramer, I don’t know why you voted to let insurance companies go back to denying coverage for pre-existing conditions. But I know Heidi would never do that.’ "

Heitkamp is talking about several votes Cramer cast in 2013 and again in 2016 to repeal the Affordable Care Act. Let’s take a look at what they did.

Key takeaways

• 300,000 includes everyone with some sort of pre-existing condition. The people whose health plans might be at risk is a fraction of that.

• Cramer cast votes to both repeal Obamacare and replace it with skimpier plans.

• While these replacements kept protections for pre-existing conditions in place, they stripped some of the safeguards that make those plans affordable today.

Cramer and the Affordable Care Act

The Affordable Care Act made sure that people without health insurance got coverage. The problematic sector was the individual, or non-group, market: those not covered by their employer or by the government. They form the smallest part of the market.

Before the Affordable Care Act, people in that market could get turned down for having a pre-existing condition (anything from hay fever to cancer); could get charged more for it; or could be offered a health plan that excluded its coverage. Now, all of those things are illegal.

The Heitkamp campaign said there are 300,000 individuals with pre-existing conditions in North Dakota, rounding the 275,556 calculated by Health and Human Services in 2009 and 316,000 calculated by the Center for American Progress.

Those numbers are credible, but the majority of those individuals are covered by group plans. So voting to repeal the Affordable Care Act is not a vote to strip coverage from all 300,000. Instead, it would jeopardize coverage for the non-group market, which covered 9 percent of North Dakotans in 2016. The ad does not make clear whether Denise is in the group or individual market.

Heitkamp sent us Cramer's votes to strip funding for the Affordable Care Act and one vote to repeal it. Cramer’s campaign told us he has always supported coverage of pre-existing conditions, pointing to the American Health Care Act and Graham-Cassidy.

Whatever Cramer’s wish is, his votes jeopardize coverage as it stands for pre-existing conditions in the individual market, according to Karen Pollitz, senior fellow at the Kaiser Family Foundation, a nonprofit health care organization.

By the letter of the law the bills protect pre-existing conditions. But they take away the mandate that everyone be insured and the subsidies that make that affordable. In practice, plans for individuals in the nongroup market would become exorbitantly priced, if available at all.

Our ruling

Heitkamp said Cramer voted to let insurance companies go back to denying coverage for 300,000 North Dakotans with pre-existing conditions.

Cramer's votes technically included provisions to prevent health care companies from denying coverage to people with pre-existing conditions. But the limits of what insurance companies could charge would have been watered down, which would have sent premiums skyrocketing, experts say, to the point that coverage for many would be unattainable. However, only about a tenth of the 300,000 people in the ad would be directly affected by the laws in question.

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